Ending the Therapeutic Relationship: Creative Termination Activities

Amy Bucciarelli, MS ATR-BC, LMHC, Board Certified Art Therapist, helped Frank “Dylan” Dinkins make a painting for his parents. Bucciarelli works with pediatrics patients at UF Health Shands Children’s Hospital.

Termination is a highly important part of every therapeutic relationship that should be addressed throughout each stage of the process. While many adult clients have the ability to easily think back to their experience in therapy, for youth this is often more difficult.  Because of this I like to provide clients with some sort of physical representation of their time in therapy that will help them reflect on their experiences, highlight their strengths, remind them of what they learned and provide them with tools they can use to help prevent regression, and even continue their progress on their own.

These activities let you both reflect on their time in therapy and transition out of services in an engaging way. I’ve also found that using metaphors often helps young clients to better understand termination and makes after-care instructions more salient.  Below are some ideas for creative termination activities that are easily adaptable to fit your clients’ needs. I am not sure of the origins of all of them, so please let me know if there is someone that I should be citing.

Session Trackers

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I recently spoke to an intern who was confused when a number of her clients seemed surprised when it came time to terminate, despite her verbal reminders.  It is sometimes helpful for young children to be able to have a visual representation of how many sessions are left, and it can help them better prepare for termination.  One way to do this is to create a session-tracking chart.  In the examples above clients color in one image, or choose a sticker, at the end of each session.  The activity is quick and also provides a good opportunity for therapists to check-in with clients and help process any feelings surrounding termination that come up throughout the process.

Ready to Set Sail: Termination Activity

By Jodi Smith, LCSW, RPT-S at “Play is Powerful”

Supplies: Toy boat, paper boat, paper mache boat, box with a boat drawn on it, etc.

Directions:

  • I’ve found that the use of metaphors increases the amount of information that clients retain and internalize so I use them frequently in termination.  Start by explaining to the client that because of the progress they have made they are ready to sail off on their own.
  • Reflect on what that feels like and process any anxiety, and transition into talking about all the things they will “take” with them to help with their journey.
  • Have the client answer each question and write their response on the back of the cards.  The boat will contain cards related to tools they will take with them (supports, coping skills, etc.), things that may get in their way and strengths (as identified by the client and therapist).  Along with my pre-made cards, I also give them blank ones.

Treasure Chest Termination Activity

Supplies: Treasure box (Michaels Crafts has wooden “treasure” boxes that are cheap and easy to decorate.  A link to directions on how to make a paper one can be found here; Stick-on plastic jewels (found at crafts stores, oriental trading co., etc.); Small note cards (cut to fit the box); Pen.

Directions: First, have your client decorate a treasure chest.  Then stick a jewel to each card as your client writes down the “task” that is assigned to that specific color (see below).  On the back of the card, they include a specific example of how what they identified has helped them in the past and/or how it will help them in the future.  Below are examples of possible color codes, but you should change them to meet your client’s specific age and needs.  In the end, the chest will be full with a stack of jeweled cards.

  • Blue: Strengths (Identified by both the client and therapist)
  • Red: Coping skills
  • Green: Supportive people in their life
  • Orange: Resources from therapist (ex. hotline numbers, therapist referrals or directions for reenrolling in services.)
  • Purple: Self-care activities
  • Pink: Inspiration (future goals, motivational quotes, etc.)
  • Yellow: Things they have learned in therapy

 Suitcase Termination Activity

At termination, your client is finally ready to continue their journey on their own.  Even though they will be leaving you behind, they can pack up everything that they have learned during their time with you to take with them.  This metaphor is easy for most people to identify with and it is a fun activity.

Supplies: Plastic or cardboard suitcase; Blank sticker labels; Paper luggage tag; String; Cards; Travel stickers.

Goals: Process termination; Provide transitional object; Help prevent regression; Identify accomplishments, goals, coping tools, etc.

Directions:

  • Have your client make and/or decorate their suitcase.
  • Then they write something they will “take with them” from their time in therapy on each card provided (I print cards with travel clip-art on the back).  These can be things they have learned, coping skills, supports, resources etc.
  • You can also integrate this with the after-care kit I posted.
  • On the labels, they write or draw goals they have accomplished.  (Like the old suitcases in movies that are covered with stickers of past travels).  I also provide additional travel stickers.
  • On the luggage tag, they write where they are going next.  This could be a new life stage (ex. my 8th graders usually write “high school”) or a goal they would like to accomplish that the contents of the box will help them achieve on their own.
  • Process feelings about termination throughout the activity.

Therapeutic Goodbye Cards

letter

This is such a simple, yet powerful termination activity.  I got this idea from a client who gave me a very touching thank you note during our last session.  It is something I have kept and reflect back on, and I realized that it could potentially play a similar role for a client.

  • The focus of the content is on the journey through therapy and what has been accomplished.  I highlight strengths, review coping tools and lessons learned, and express my thoughts about termination. In the end, I usually include instructions of what to do if they decide to enter therapy again.  You could also have the client write a letter to their future self that they can read when they are struggling.

Summer Bucket List

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I put a therapeutic twist on this summer craft.  Most school therapists are unable to see clients throughout the summer but may pick up treatment again during the following school year, which is not ideal.  This activity can help encourage adherence to after-care recommendations.

Directions: Have your client design a bucket that will help them to continue your work together on their own and prevent regression.  On the back of the paper bucket, they can write goals for the summer, self-care activities, etc.  For the 3D buckets, these can go on cards placed inside the bucket.  On the shovel, they write down “tools” that will help them to accomplish their goals (social supports, coping skills, resources, etc.)

You’ve Got Mail: Group Termination Activity

mailbox

Directions: First, have your clients create their own paper mailbox.  Then, each person, including the therapist, writes a short note to every other member of the group.  You can instruct them to write something that they have gained by knowing that person, a strength they can identify in that person, a motivating message, etc.  The notes are then placed in the mailboxes for the group members to take home.

Graduation 

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Certificates are very simple to create in programs like Word, Pages, etc., and are a good wrap-up for clients who have worked hard to meet their therapeutic goals.  In my example, I left space to write specifics about progress, accomplishments, reflection, etc.  One the last group session we have a “graduation party” where we have fun, reflect on our time together/progress made, and process termination.  They are then presented with their certificate.

Instigating Change: The Public Perception of Social Work

change 1Over 25 years as an Australian social worker, my experience is that a good proportion of the population relate “social worker” to someone who removes children or someone who butts their nose into other people’s business. Often, it’s perceived that we practice our “stuff” in a government department, hospital to find elderly people nursing homes, or in a child welfare setting to assess family functioning.

How well do we as social workers educate our target groups about the services we provide? What do the general public perceive a “social worker” to be, and whose responsibility is it to promote our profession? Making the choice to create a career out of being a social worker has its disadvantages. After graduation it really didn’t take me long to stop calling myself a social worker. I found it to be a great conversation stopper at social gatherings. “So what do you do?” “I’m a social worker”. Responses ranged from  “oh okay, so you work with dole bludgers” to “oh you’re one of those do-gooders” to “ oh that’s interesting, so what is it that you actually do?”

Social work is a profession. Yet as a profession, it is still battling recognition in both the allied health sector and in the public arena. Historically, we were the charity workers, literally the “do-gooders”, those who gave up their time to help the disadvantaged. Our work was viewed as practical, bandaid, prescriptive, and often linked to churches who traditionally established programs to assist the poor.

Thankfully by the time I attended university in the early eighties, some semblance of a professional identity had been established, albeit still vague to the masses. “Change Agent” was one of the most apt descriptions to me at the time, and one that I use frequently today when explaining what it is that social workers actually do. Also, I was taught the term “change agent” crosses the boundaries of the three distinct areas which consist of casework, group work. and community work.

No, I did not learn how to hand out a welfare cheque to a client. Casework meant one on one counselling intervention to help an individual or family function better. No, I did not learn how to ladle the soup into bowls, and tuck people in at the local homeless shelter. I learnt how to facilitate groups, empower participants, foster mutual goals and maintain enthusiasm. And finally no, I did not learn how to partake in the local Neighbourhood Watch meetings to ensure the safety of the local community. I learnt to focus on community assets as opposed to disadvantages, inspire community participation with action towards change, and advocate on behalf of groups whose disadvantages place obstacles in the way of being heard.

When social workers are viewed as “agents of change”, it does more than just clarify our role to the public. It actually places an obligation back to the profession to ensure positive change happens for our clients. It isn’t enough to sit in the geriatric ward of the local hospital and simply look after the practicalities of a nursing home booking without checking on coping skills. Or to hand someone a food voucher without exploring ways to improve their situation in the long term.  It doesn’t cut it to sit in the office at a community centre booking external hirers and stating boldly you’re achieving something for your community. It’s not enough to sit at the head of the table at a group session and be the perceived expert whilst using psychological jargon only another professional would understand. These methods simply maintain the status quo – they do not inspire change, nor do they empower people to carry out change in order to reach their full potential.

So perhaps we need to look at our own profession and ask ourselves, what is it that we as a group are doing to maximize our profession’s full potential? Why is it that the public perception of our role is still not accurate, let alone widely known?  How do we achieve a better “branding” of the words social work and social worker?

“The general public” are our clients. They’re our target group(s).  There are a whole team of professionals including psychiatrists, psychologists, social workers, social scientists and welfare workers, who aim to empower them to lead more fulfilling lives.   Yet Mr and Mrs Public don’t understand the differences in our qualifications. Our “consumers” actually don’t understand the “service” they’re purchasing, nor the good, the bad and the relevant. They just want “help” or “therapy” or “representation” and more often than not, the term “psychologist” will come to their minds. How do we change this to ensure our clients will understand their choices?

It’s time to make change to the public perception of social work. Clarify our skills in simple, layman’s terms. What is our core business? How do you describe “social work” to your family and friends?  How would you make a visit to a social worker sound appealing or helpful if you had to make a poster to promote our profession?

Start the ball rolling, leave a suggestion below as to how YOU would educate the general public to increase understanding of our skills and start “branding” our profession!

Is Your Candle Burning from Both Ends: Examining Burnout and Self-Care

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“You can’t help others until you first help yourself”. “Don’t burn your candle from both ends”.

I used to hate those cliches, but when it comes to therapist wellness, it’s true.

My first experience with burnout happened just 3 short months after graduating with my Master’s degree. I move across the country, and I dived head-first into the real-world of therapy. My eyes were opened to a whole new world of disillusionment that I could never have been prepared for.

I experienced an episode of burnout, and I know it won’t be my last.  Along the road to getting my licensure as a Licensed Professional Counselor (LPC), I encountered things that would make even the most resilient people burn out, if not get a little crispy around the edges.

  • I saw ethics violations and fraud that hurt clients and the entire mental health system is full of corruption.  I reported a provider to a licensing board, lost my job and relocated.
  • I’ve had 5 jobs in just over 2 years. I worked overtime at roughly $15 an hour with student loan debt weighing heavily in the back of my mind. One agency I worked for, closed suddenly overnight after a few weeks of my pay checks bouncing. I also had to pay for weekly supervision in order to keep my associate license.
  • I worked in homes with roaches, smells and sights that seemed to be right out of horror movies. I saw the effects of child abuse and sat back and felt hopeless when CPS couldn’t help. Poverty, inequality and suffering were in my face every day.
  • I got physically and verbally attacked by clients. I was providing services in rural areas where guns were prevalent and cell-phone service was not.
  • I frequently felt undermined by administrators. I was told that the letters after my name didn’t matter, even though I had worked so hard for them. I was told I needed to “earn my stripes” even though I had education, experience, and a license.
  • I was on-call for emergencies 24 hours a day, 7 days a week, 365 days a year. I came to associate my ringtone with crisis and would cringe when I heard it.

These things do not make me a martyr. These are the typical experiences of a new therapist.  I share them in the hopes of increasing awareness, decreasing the isolation and shame other therapists feel. I hope to open the door to discussions about how we can make systematic changes to make things better.

Improving the workplace for counselors, and in turn, improving services for clients with mental health needs will be a forever on-going process. This topic could easily be it’s own post, book, or series of books.

In the mean time, how will you stay healthy, engaged, and able to serve your clients?  Here is what has helped me along the way:

  • Embracing the inevitable and learning to recognize the signs of burnout. Burnout will happen. Be ready and keep a look-out.  It can mean feeling exhausted, numb, hopeless, helpless or depressed.  It could mean feeling anxious, panicked and unable to sleep.  Other signs include relief when clients cancel sessions, dreading going to work in the morning, client-blaming, or being sarcastic, cynical and resentful.
  • Receiving lots of supervision from other therapists.  One-on-one direction from therapists with more experience than me was priceless.  Group supervision also helped decrease my sense of isolation and boosted my confidence.
  • Becoming a regular therapy client. I believe therapy is effective for helping people cope with a stressful life.  That is why I’m a counselor, and it is also why I am not afraid to seek counseling for myself.
  • Taking steps toward basic self-care. Keep eating, exercising and sleeping habits healthy. Avoid alcohol and drugs.
  • Maintaining relationships with family and friends. Build your social support network. Stay connected to your community.
  • Taking time off. Get out of town or turning off the phone. It’s ok to un-plug and relax, even if it is just for a few minutes.
  • Seeing the big picture.  Every therapist has a vision and a reason they entered this field.  Remind yourself of it.
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